Maria Pia Prudenzano

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.

Lack of habituation of nociceptive evoked responses and pain sensitivity during migraine attack

OBJECTIVE The aim of the present study was to investigate the habituation of subjective pain sensation to CO(2) laser stimulus, in relation to the amplitude modifications of the cortical evoked responses (LEPs), during both the migraine attack and the not symptomatic phase. METHODS Fourteen migraine patients were selected and compared with 10 healthy controls. Eight patients were evaluated during both the pain-free and the attack phases. Three following series of 20 averaged LEPs were recorded, stimulating the hands and the supraorbital zones: during the attack, two consecutive series of 20 averaged LEPs were carried out. The subjective sensation was requested for each laser stimulus, using a 0-10 points Verbal Rating Scale (VRS). RESULTS In normal subjects the N2-P2 waves amplitude showed habituation across the three repetitions, which correlated with the habituation of the subjective rating of the stimulus. During the not symptomatic phase, patients showed a lack of habituation of the N2-P2 amplitude when the hand and the face was stimulated, with a pattern of increase of the pain rating across the three repetitions; in addition there was a lack of correlation between the LEPs amplitude and the subjective sensation. During the attack, the LEPs amplitude and the pain rating were increased when the face was stimulated, but they did not habituate across the two repetitions, likely the pain-free condition. The percent LEPs amplitude variation across the three repetitions correlated with the main indices of migraine severity, mainly when the supraorbital zone was stimulated. CONCLUSIONS The abnormal cortical excitability in migraine could condition an anomalous behavior of nociceptive cortex during the interictal phase of migraine: it persists during the acute phase, and correlates with the frequency and duration of migraine. SIGNIFICANCE The reduced habituation of the nociceptive cortex may concur with the onset and evolution of headache.

Insomnia, quality of life and psychopathological features

Most of the studies about chronic insomnia focused only on specific features, providing in this way a partial outlook of the problem. The aim of this study was to examine a sample of chronic insomniacs from different points of view, by estimating the prevalence of stress, psychopathological symptoms, psychiatric disorders, changes in quality of life and illness behaviour. Forty-three patients (54.4%) experienced some psychosocial stressors in the last 6 months preceding the enrollment in the study. More than 55% of insomniacs reported symptoms of psychopathology. One or more than one psychiatric disorder was diagnosed in 61.5% of insomniacs. Life events could play a role in facilitating the transformation of a psychopathological symptom in a psychiatric disorder, since patients with a psychiatric diagnosis showed a higher percent of stress. The more noticeable disability in the group of insomniacs with psychiatric disorders and the absence of a corresponding worsening in illness behaviour suggests that insomniacs feelings about their health status are so negative to be not fatherly worsen by comorbidity in spite of a worsen disability. The evaluation of insomniacs should be as much detailed as possible, without neglecting tests for the evaluation of disability and illness behaviour, which are important not only for a correct diagnosis but also for monitoring the effects of therapies.

Stress and chronic headache

Abstract The aims of this study were to assess how stress affects chronic headaches, and in particular to determine whether events play a role in the transformation of an episodic headache into a chronic form. A population of 267 Italian patients with chronic headache (headache present on average more than 15 days per month) was studied. Our results confirm a triggering role of stress on headache. We also found that episodic headache (migraine in most patients, 74.1%) preceded the development of a chronic form in about 90% cases. Among these patients, in 44.8% a stressful event correlated with the transformation. Analysis of these events revealed that minor events played a greater role than major life events, suggesting that patients with transformed headache are characterised by a different way of reacting to stress.

The importance of anxiety and depression as factors in chronicization of primary headaches

Abstract A multicenter study was carried out in 10 Italian headache centers to investigate the prevalence of anxiety and depression in patients with chronic daily headache(CDH). The study investigated 219 patients (171 F; 48 M) including 53 cases of chronic tension-type headache (CTTH), 99 cases of CTTH+ migraine and 67 cases of transformed migraine (TM). The type of headache diagnosed at the beginning was episodic tension-type headache (ETTH, n=32), ETTH + migraine (n=2), CDH ab initio (n=22), migraine with/without aura (n=151), not classifiable migraine (n=7) and not classifiable headache (n=3). The assessment of anxiety and depression was carried out using a Zung self-rating scale for anxiety (Zung A) and for depression (Zung D). The results show that anxiety and depression levels, in each group, were related to sex (F>M). Anxiety, but not depression, was related to the length of chronicization process. Anxiety and depression did not correlate with type of headache at onset, with ongoing headache or, surprisingly, with the abuse of anti-inflammatory drugs. These data suggest the chronicization is a biological and psychological trait.

Psychologic factors in chronic headache: assessment by means of the SCL-90-R inventory.

Headache, has been carried out with the symptom check list (SCL)-90-R inventory. The results obtained were viewed in relation to sex, age, illness onset, and illness duration. Females showed a positive correlation of somatization with present age and with age at onset of illness and a negative correlation of interpersonal sensitivity, hostility, and paranoid ideation with present age and age at onset of illness. Men showed a negative correlation of obsessive-compulsive and paranoid scores with age and a positive correlation between onset of illness and somatization. Data were also analyzed by cluster analysis, which showed underpopulation with peculiar patterns of symptom profile. A prospective, long-term epidemiologic study could provide more conclusive results.

Psychopathological comorbidities in medication-overuse headache: a multicentre clinical study.

In medication‐overuse headache (MOH) patients, the presence of psychopathological disturbances may be a predictor of relapse and poor response to treatment. This multicentre study aimed to assess the occurrence of psychopathological disorders in MOH patients by comparing the incidence of psychopathological disturbances with episodic migraine (EM) patients and healthy controls (HC).

Chronic daily headache: personality study by means of computerized MMPI-2

Abstract Unresolved questions in headache research are the roles of drug abuse and psychopathology in headache disorder, especially in chronic daily headache. We investigated the utility of the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2) for assessing psychopathology in chronic daily headache patients. Chronic headache sufferers gave characteristic responses on Hy (hypochondria), D (depression) and Hs (hysteria) scales which are known as the “neurotic triad”. Although our data suggest that the MMPI profile types do not discriminate between different diagnosis groups and fail to determine whether psychopathological traits predispose to drug abuse, they nonetheless confirm the importance of psychological assessment as an essential step in the decision to seek medical help for headache.

The comorbidity of migraine and hypertension. A study in a tertiary care headache centre.

Literature data concerning the comorbidity of migraine and hypertension are conflicting and lacking in consistency [1–4]. This study was designed to evaluate the distribution of hypertension in a sample of migraineurs in comparison with a group of tensiontype headache (TTH) patients. Hypertension prevalence was more elevated in headache sufferers than in the general population. This finding might be due to a Berkson’s bias; in fact individuals seeking medical care often show a high rate of association between two medical conditions which may be independent in the general population [5]. The highest hypertension prevalence was found in patients with TTH, supporting the hypothesis that this type of headache might be based upon vascular mechanisms [6].

Tertiary treatment for psychiatric comorbidity in headache patients

The presence of significant and confounding psychiatric comorbidity is greater in patients attending headache clinics than in headache patients from the general population. The frequent comorbidity of headache with generalized anxiety disorder can take advantage of the administration of benzodiazepines. With regard to depression–related headache, it’s wellknown that the antidepressive drugs can improve migraine as well as tension–type headache. Antiepileptic drugs give one more good opportunity. The recognition of a psychiatric comorbidity is mandatory for an accurate management of the patient beacause prevents the clinicians from using any drug that might be dangerous for a mysdiagnosed psychiatric disturbance and often permits to administer medications that can efficaciously control both headache and psychiatric disorders.